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Summary table of health records of urban and rural residents
Summary of health records of urban and rural residents 1
The establishment of residents' health records is a standardized record in the process of medical and health institutions providing services to residents. It is a systematic record document that centers on residents' health and runs through the whole life process, covering all kinds of health-related factors and residents' enjoyment of basic medical and health services. The state lists the establishment of residents' health records as a basic public health service project. In order to do this work well, our _ _ _ township health center quickly organized the staff of the whole hospital to seriously study the spirit of the document. On the basis of 20__ years' work, the summary report on the establishment of residents' health records in _ _ hospitals is as follows:
I. Work completion
My township governs 8 administrative villages with a population of about 9753. On April 38+00, 2065, about 4,388 health records of residents should be established, including 4,380 paper and electronic records, with a filing rate of 44.9%. 20 1 1, 2,930 health records of residents should be established, and 3,000 health records were actually established, including 3,000 paper files and 3,000 electronic files, with a filing rate of 30.7%, accounting for 75.6% of the total workload and 7,380 health records of residents.
Second, the method of work implementation
(1) The method of gradually breaking the whole into parts. There is a unified planning of township hospitals, which is decomposed into villages. There are village clinics that report the number of people to township hospitals after statistics. We organize physical examination and filing in a unified way.
(2) Farmers voluntarily and actively guide. After our unified planning, we organized the training and study of doctors in each village, and then widely publicized it in each village to let people know the benefits of this policy and consciously participate.
(three) the principle of standardizing the filing and seeking truth from facts. We arrange special personnel to seriously study the spirit of the document, go out to learn the experience of the unit where the document is prepared, and arrange special personnel to establish health files and information entry of health files to ensure that this work is carried out actively, effectively and correctly.
Third, the results achieved.
At present, among 4380 people in our physical examination, about 100 people suffer from hypertension, the prevalence rate is 2.2%, and some of them have different degrees of smoking and drinking history; There are about 10 patients with coronary heart disease, and the prevalence rate is 0.2%. Some of them are overworked all the year round, while others suffer from mental illness and disability to varying degrees. Several years of residents' health records have laid a solid foundation for comprehensive and timely understanding of residents' health status.
Fourth, risk factor analysis
At present, according to our statistical results, people in my township generally lack reasonable exercise and have a large amount of physical labor; Unreasonable life and behavior habits; There are misunderstandings in their ideological understanding, and they can't attend the physical examination on time, which is a common factor affecting their health.
Problems with verbs (abbreviation of verb)
Due to the large number of migrant workers and floating population, the actual number of people at home is relatively small. It is difficult to establish health records, and the work progress can't keep up with the plan. My hometown has inconvenient transportation, scattered residence and poor service coverage.
Working face of intransitive verbs
According to the current situation, we decided to improve the work plan and design an effective plan after all-round training for the staff of our hospital and the person in charge of the village clinic, combined with the actual situation. We decided to provide door-to-door service from village to village, further increase publicity efforts, improve publicity awareness rate, and strive to let people in my township know the importance of their own health and the necessity of regular physical examination and actively participate in it; Let residents' health records really serve the masses.
Summary of health records of urban and rural residents II
Residents' health record is an important public health work in the national medical reform plan, which is related to the physical and mental health of each resident and the improvement of the health level of the whole country. It is the unshirkable responsibility of our medical staff to establish good health records for residents, and it is also a major support for public health projects in the national medical reform work, so that all public health projects can be implemented and benefit the whole country. In order to further strengthen the management norms of residents' health records, our hospital has conscientiously implemented the requirements of national basic public health services and related documents at higher levels, and combined with the work plan at the beginning of the year, the work situation in the past year is summarized as follows:
First, leaders attach importance to it.
In order to promote the management of residents' health records in the jurisdiction, our hospital set up a leading group for the management of residents' health records, headed by President Liu Benqiang. All members of each department work together in an orderly manner and implement them one by one according to the requirements of relevant documents of higher authorities. At the same time, we will invest a lot of people, money and materials to overcome difficulties, correct our thinking, put the responsibility on people, and promote the management of people's health records in an orderly manner.
Second, the work content
(1) Publicity and training
In 20__ years, organize specialized personnel to carry out training on filing, systematically master the requirements and technologies for the establishment, management and use of residents' health records, establish necessary medical knowledge and skills, and operate and apply the health record information system. Explain the requirements for filling in items of health records, that is, all items must be filled in accurately except those that do not need to be filled in, and the information must be known in detail with residents in order to achieve the accuracy and completeness of the files.
Carry out extensive publicity, make it a household name, everyone understands, and let residents actively support the smooth completion of our filing work.
Establish health records
1, filing contents: including personal basic information, health examination, health management records of key populations and other medical and health service records, etc.
2. Filing method: The doctor is responsible for providing services for the residents in the area to establish health records. Responsible for health investigation and basic health examination such as weight, height and blood pressure, and establish health files. On this basis, health records are established for key groups through on-site service (investigation), disease screening and health examination.
(3) Management of health records
1. Establish health record personnel as managers.
2, the establishment of health records should follow the principle of voluntary and guidance, in the process of use should pay attention to protect the personal privacy of the service object.
3, do a good job of backup of health records.
4. Standardize the management of health records. Establish a management system for consulting, reading, recording and storing residents' health records to ensure convenient use, long-term preservation and standardized management.
(4) Work flow of health records
20__, the resident population of the jurisdiction 1 1700, the establishment of health records 77 14, electronic files 77 14. Registered elderly 72 1, hypertensive 3 165438, diabetic 65438. This year, 7 1 person was added, including 47 elderly people, 3 chronic diseases, 4 severe mental patients, 0-6 year-old children 17 people, and pregnant women 1 1 person.
In recent 20 years, our hospital has made some achievements in establishing residents' health records. However, some residents are not very familiar with the purpose and significance of establishing residents' health records, and cooperation in doctor examination and inquiry needs to be deepened. Migrant workers can't establish their own information in time, and there are still many shortcomings in their work. Our hospital needs to continue to study and practice in depth, overcome difficulties, have high standards and strict requirements, and strive to make the next step more perfect.
Summary of urban and rural residents' health records 3 pages
The health record of community residents is not only one of the basic public health services in China, but also the prerequisite, foundation and key work to carry out other community health services. Only by doing this work well can the community health service, disease control and maternal and child health care institutions better understand and master the basic health status of residents in their jurisdiction, make correct community diagnosis and formulate targeted community health intervention measures, so as to provide residents with medical treatment, prevention, health care, rehabilitation, health education and family planning technical guidance services more effectively. To this end, we have invested a lot of manpower and material resources, so that this work has achieved remarkable results, which are summarized as follows;
First, the key lies in the "three leading", the planning scheme is one step ahead, and the measures should run through.
We should let the team pay attention to and devote themselves to the establishment of residents' health records. First, leaders of centers, service stations and health records teams should take the lead in changing their concepts and unanimously realize the importance and necessity of establishing residents' health records. Residents' health records are obviously different from outpatient medical records and inpatient medical records. The former is a systematic file or database to record residents' health status, which provides general practitioners with comprehensive basic information of patients in continuous treatment, health care and rehabilitation, and is also a tool for community health workers to expand and deepen clinical experience and even scientific research. The latter two are only records of the diagnosis and treatment of a disease. If health records are established and standardized management is carried out for residents with hypertension and diabetes, we can understand the residents' medication habits, methods and problems in treatment; Carrying out health examination can understand the actual incidence and risk factors of gallstones and fatty liver in elderly residents; Through in-depth community and household surveys, we can also understand other health conditions of residents, such as their community, family and cultural background, and lay the foundation for the next community health intervention. In our work, we realized that we should first strengthen leadership, set up a leading group for residents' health records management with the director of the center as the leader, formulate work plans and implementation plans, improve service processes and pay attention to the implementation of measures. The key lies in the full participation of the person in charge, who can understand and master the first-hand information and solve the problem on the spot at the first time.
Two, careful arrangements, improve the process, division of labor and cooperation, and strive to meet or exceed the standard.
In order to ensure that residents' health records meet or exceed the standards on time, in quantity and quality, we must first make a good plan, adopt various filing methods and use them flexibly according to specific conditions. For example, we use the three-day "Community Chronic Disease Management and Health Education Day" of each service station to focus on filing, and at the same time cooperate with household surveys to supplement and improve the filing and update files. Specific work should formulate relevant appropriate rules, such as arranging appropriate household survey time and setting up a "full-time and part-time" health file group composed of centers, service stations, neighborhood committees or properties. When choosing a residential area for filing, it should be a residential area or a community with similar cultural background, so that residents can accept it. Establishing a scientific and practical service process is conducive to improving the efficiency of filing a case, such as the matching team of men and women, the dress of wearing a badge, the appropriate time to enter the house, and the measures to conduct a centralized investigation in a certain community or community. In order to improve the efficiency and quality of filing, measures such as division of labor and cooperation, division of labor without separation, sorting while filing, and centralized improvement are taken. According to the requirements, the record must reach the standard and strive to exceed the standard.
Third, give full play to advantages and cooperate in many ways; Strengthen training and improve quality; Be pragmatic and pay close attention to the key points.
Take the center as the leader and backbone, and give play to its decision-making and technical advantages; Taking the service station as the starting point and platform, taking advantage of geography and familiarity; With the help and guidance of the neighborhood Committee or the property, with the help of its network resources and the advantages of the landlord, the three parties joined hands to participate in the filing work. It is very important to establish a true and complete resident health record for future work. Therefore, in order to improve the filing quality and ensure the accuracy and completeness of the collected first-hand information, it is necessary to strengthen the specialized technical training for relevant personnel. The establishment and use of residents' health records should be based on the actual situation and the principle of convenience, practicality and future integration. It is necessary to make a long-term plan, implement it step by step, improve its practicality and operability, and gradually improve it. For example, due to factors such as insufficient attention, undisclosed electronic files and mostly paper files, even filing may be a "dead" file or a "shelved" file; When business is busy, it is unrealistic to rummage through thousands of files with minor injuries such as colds and colds.
Therefore, under the current immature conditions, in order to give full play to the role of residents' health records, we adopt the joint management of centers and service stations, and take hypertension, diabetes and the disabled as key groups for filing and key management, so as to make them live and useful files. The specific method is to combine health education, chronic disease management, free physical examination and other activities to manage and update files, which is true, pragmatic and effective.
Fourth, long-term planning, decomposition of difficulties, step-by-step implementation, handy.
Filing according to the requirements, making no files into files, and combining with the actual file management, making files into "living" files. If the real health records of residents are not established, it is impossible to screen the target population such as residents with chronic diseases such as hypertension and diabetes, to grasp the number of elderly people and children under 3 years old in the community, and to smoothly carry out the work of community health services. Therefore, according to the actual situation and capacity of the center and the station, we make plans and implement them step by step in line with the principle that archiving is only the basis and living files are the purpose of archiving. If we want to build, we will build real files and usable files. According to the residents' health records, select the target population who need chronic disease management and health education. We have managed residents' health records and chronic disease records in a unified way. At present, the residents with chronic diseases in the jurisdiction have been gradually brought into the central control, making this part a living file, which has obviously improved the filing rate, management rate and control rate of hypertension and diabetes.
Summary of health records of urban and rural residents 4 pages
Under the correct leadership of the Municipal Health Bureau, with the active cooperation of doctors in Baocun and rural areas, the implementation plan for the management of residents' health records in basic public health services has been earnestly implemented, and the filing work has progressed smoothly. The work is summarized as follows:
First, actively carry out project training.
Hold regular meetings every month, public health meetings and training courses attended by hospital directors, personnel in charge of project work, doctors in Baocun village and rural doctors. It laid a foundation for completing the project work with good quality and quantity.
II. Archiving of Residents' Health Records:
By June 25th this year, 26,990 people had been put on file, with a filing rate of 84.65%. Electronic filing personnel are 2392 1 person, and the filing rate is 75.02%. Among them, there are 74 elderly people over 65 years old, patients with hypertension, patients with diabetes and patients with severe mental illness.
Main measures taken:
The first is to strengthen organizational leadership.
A project work leading group and a Baocun group were set up to take charge of filing. Establish and improve various work systems, clarify responsibilities and implement them to people;
Second, extensive publicity and mobilization.
Strengthen the publicity of the whole town, and use radio, publicity materials, slogans and other means to make the broad masses of the people realize the content and significance of basic public health services.
Third, strengthen supervision.
Our hospital's free medical team visited the countryside for more than 20 times, and checked the registered telephones irregularly. Effectively ensure the smooth development of filing work and the quality level of work.
Main problems:
1. Due to various reasons, some grass-roots rural doctors lack enthusiasm and sense of responsibility, and their working attitude is not positive or serious. The quality and quantity of filing are poor.
2, the file update rate can not meet the requirements.
In a word, the filing of residents' health records has made some achievements, but there are also some problems. Therefore, in the future work, we should constantly find out the problems that restrict the filing work, study and formulate solutions to the problems, and ensure the high efficiency, high quality and high level of health file work.
Summary of health records of urban and rural residents 5 pages
In 20__ _, faced with the new situation, new policies and new requirements, Shiqiaoyi Health Center paid close attention to the fine management of basic public health services, and took effective measures to strictly control the dynamic management and key points of health files according to the requirements of the National Basic Public Health Service Standard (20th edition) and under the careful arrangement of the District Health Planning Bureau and the District CDC. The health records and old death records with incomplete information and problems were rectified and cleaned up, and the "zero distance" service was provided for residents in combination with the ongoing family doctor signing and health poverty alleviation actions, which really made the residents in the jurisdiction realize the benefits brought by the policy. At the same time, strengthening internal management, implementing performance appraisal and fully mobilizing the enthusiasm and initiative of workers and rural doctors have achieved good results. The filing work of basic public health service residents in our hospital is summarized as follows:
First, strengthen organizational leadership and implement work responsibilities.
In order to ensure the smooth progress of basic public health services, our hospital set up a leading group for basic public health services with the president as the team leader, with full participation, covering the whole people, and defining the first responsible person for each work; Formulated a special implementation plan for public health work with operability and feasibility; Implement a monthly supervision system from township to village; Set up a special service working group and technical group for residents' health examination, and implement basic public health services for residents in the area by means of village-to-village investigation, unified physical examination and follow-up management services.
Two, standardize and orderly management of residents' health records.
The total population of our town is 3464 1. By the end of 20__ _ 10, 32,093 people had been filed, with a filing rate of 92.64%, and 298 18 people had been established, including 4,087 elderly people over 65 who were included in the management of key population, with hypertension.
(1) Intensify publicity to raise residents' awareness of actively filing documents. In order to improve the awareness of residents and floating population who have lived in our hospital for more than half a year to actively participate in filing, our hospital has carried out various forms of publicity and education activities to let every resident know the significance of residents' health records, and actively cooperated with the filing working group of our hospital to successfully complete the filing of residents.
(two) continue to strengthen personnel training, strengthen service awareness. In order to ensure the quality and quantity of residents' health records are completed, this year our hospital will continue to provide professional training to every staff member involved in the establishment of residents' health records, strengthen the importance, necessity and standardization of the establishment of health records, and master their own work and filing procedures skillfully.
(three) the implementation of household filing, unified coding, the establishment of a standardized file directory in the village. In order to strengthen the household registration management of health records and effectively improve the quality of special services for key populations, the residents in the jurisdiction are filed by households, and the 17-digit file code is compiled according to the requirements of the new national standard, and the list and file directory of the jurisdiction are established by villages.
(four) the implementation of dynamic management of health records of residents. Seriously carry out the update of residents' health records, summarize the update of health records every month, and update the information of newborns, dead accounts, floating population and floating population in that month; When a patient is in a medical institution for medical treatment or hospitalization, he/she should fill in the medical form in time and update relevant information; Update residents' health records through the information obtained from chronic disease follow-up and health examination.
(5) Complete the rectification of problem health files. According to the requirements and deployment of the higher authorities, our town rectified 27 problematic health records and completed the information improvement of 27 files without ID cards. Create new files 140, maintain file information 133, and initially complete the rectification of health files.
(six) the village archives all income hospital unified management. For dynamic files, village doctors should update them in time and save them according to the corresponding norms.
Third, the deficiencies in the project work
At present, although some achievements have been made in the work of health records, there are also the following shortcomings:
(A) the lack of talent, lack of professional and technical personnel, lack of previous record-keeping experience, nonstandard service, incomplete input information, equal emphasis on public health services and medical care, and heavy work pressure on staff have affected the quality of basic public health services to varying degrees.
(2) The cooperation between village clinics and basic public health services is insufficient, the service level is limited, the personnel echelon is not reasonable, and some village doctors are older.
(3) Residents' understanding of basic public health services is far away, so it is difficult to actively cooperate with on-site filing and follow-up.
Fourth, the next step.
(1) Intensify publicity, earnestly carry out basic public health service projects, and gradually change the old ideas of community residents through publicity-attraction-re-publicity, so as to encourage them to voluntarily participate in community public health services.
(two) to strengthen the construction and training of professional and technical teams, improve the level of basic public health services.
(3) Establish a reasonable incentive mechanism and performance appraisal system to improve the enthusiasm and initiative of employees.
(four) the implementation of service standards, strengthen the construction of rules and regulations, and promote the sustained and healthy development of basic public health services.
In a word, under the care, support and guidance of the District Health Planning Bureau, the District Center for Disease Control and Prevention and the superior departments, all the staff in our hospital will work harder in the future, keep innovative thinking and careful organization in the spirit of forging ahead, pioneering and advancing with the times, and strive to do all public health services better.
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